Incident Form 2025

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The document is an Incident Form used by the Risk Management Office at The Pennsylvania State University. It is designed to collect detailed information about accidents or incidents, including time, place, property damage, and injuries. The form specifies that it should not be used for Workers' Compensation or automobile accident claims and includes sections for witness information and a description of the incident. Additionally, it contains a consent statement for students regarding the release of information to insurance carriers.

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Click ‘Get Form’ to open the Incident Form in our editor.
Begin by filling in the 'TIME & PLACE' section. Enter the date, time, city, and specific location of the incident.
In the 'PROPERTY DAMAGE' section, provide details about the owner, including their name, address, zip code, and phone number.
Next, complete the 'INJURED PERSON' section. Fill in the injured person's name, age, occupation, nature of injury, and where they were taken for medical attention.
For 'WITNESS', document any witnesses present during the incident by providing their names and contact information.
In the 'FACTORS' section, indicate the surface conditions (e.g., dry, wet) and lighting conditions (e.g., indoor/outdoor) at the time of the incident.
Finally, describe the incident facts in detail. If necessary, use a separate sheet of paper for additional information.

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What are incident examples?

What to include in a work incident report The date and time of the incident. The name of the witness or author of the report. A detailed description of the events. The names of the affected parties. Other witness statements or important information. The result of the incident.

What are incident forms for?

You can use these forms to record the results of investigating accidents, hazards and complaints or inspections of your workplace.

What are incident forms?

An incident report form is used to provide a comprehensive record of any unwelcome or undesirable occurrence that occurs within the workplace environment. This includes such things as workplace accidents, hazardous material spills, safety violations or misconduct by employees.

What is an incident documentation form?

An incident report is a formal document that records accidents, injuries, near misses, and other unexpected events in a workplace. It provides a detailed account of the incident or accident, including where and when it happened, who was involved, and any contributing factors.

How to fill out an incident report form?

You may use OSHAs 301: Injury and Illness Incident Report or an equivalent form. Some state workers compensation, insurance, or other reports may be acceptable substitutes, as long as they provide the same information as the OSHA 301. 1.